Case 1: Going forward in lack of movement

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A 12-year-old girl was referred to the paediatric gastroenterology service with a history of chronic constipation and fecal incontinence. The symptoms were present for seven years, with frequent passage of stools in the clothes. She also experienced intermittent nocturnal enuresis. There was no abdominal pain, bloating, nausea, vomiting, diarrhea, rectal bleeding, dysuria, chronic cough, fatigue or weight loss. Her history was otherwise unremarkable, with no problem passing meconium after birth and a normal stool pattern in infancy. Her growth and development were normal. The child was in foster care and a family history was not available. The patient was tried on a variety of laxative therapies including lactulose, oral polyethylene glycol and repeated rectal enemas. The patient had a difficult and protracted course over several years, with frequent stool incontinence. Cognitive behavioural therapy was provided by a professional psychologist. Due to uncertain compliance with oral therapy, lavage with polyethylene glycol via a nasogastric tube had been tried several times for fecal disimpaction. Investigations included normal thyroid function tests, serum calcium and urinalysis. An abdominal radiograph had revealed fecal loading in the distal colon. On examination, she was obese with a weight between the 90th and 95th percentiles, and a height between the 10th and 25th percentiles. Her body mass index was 29.8 kg/m2 (greater than the 97th percentile). There was no pallor, clubbing or thyromegaly. The abdomen was soft and nondistended, with no tenderness, organomegaly or masses. (A previous rectal examination conducted by the referring physician revealed stool in the rectum.) Examination of the nervous system and spine was normal. A diagnostic laboratory test was performed, which revealed the diagnosis.